How is psychosis treated in patients with Parkinson disease (PD)?

Updated: Aug 29, 2019
  • Author: Robert A Hauser, MD, MBA; Chief Editor: Selim R Benbadis, MD  more...
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In individuals with only mild hallucinations that are well tolerated, active antipsychotic treatment may not be necessary.

Pimavanserin (Nuplazid) was approved in April 2016 for treatment of hallucinations and delusions associated with Parkinson disease psychosis. It is the first drug to be approved for this condition. It is a selective serotonin inverse agonists (SSIA). It not only preferentially targets 5-HT2A receptors, but also avoids activity at dopamine and other receptors commonly targeted by antipsychotics. Efficacy was shown in a 6-week clinical trial (n=199), where it was shown to be superior to placebo in decreasing the frequency and/or severity of hallucinations and delusions without worsening the primary motor Parkinson disease symptoms (p=0.001). [114]

Use of some other typical antipsychotics can exacerbate motor symptoms of Parkinson disease and should be avoided. [23]

Quetiapine is the atypical neuroleptic agent most commonly used by movement-disorder experts, because it rarely exacerbates motor symptoms and blood monitoring is not required. However, its efficacy has not been confirmed in clinical trials. Quetiapine is used in Parkinson disease at doses much lower than those used in schizophrenia. It is usually introduced at a dose of 25 mg at bedtime and can be increased to 50 mg or more at bedtime as necessary.

Clozapine can also be used, but blood monitoring is required due to its potential for agranulocytosis and other severe side effects. [23, 115] For this reason, clozapine is usually reserved for patients who are not adequately controlled with quetiapine. Other atypical neuroleptics generally have more potential to worsen Parkinson disease motor symptoms than quetiapine and clozapine.

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